Physiotherapy following prostate cancer – The Optimise Programme

At Evidence-Based Therapy Centre we have developed a specialist physiotherapy programme to help alleviate the common side effects of treatment for prostate cancer. To our knowledge, this is the first programme of its kind in Ireland and is based on the latest research and modelled on care pathways from world leading physiotherapists and pioneers in this area of physiotherapy in Australia.

Prostate cancer is the most common cancer in men in Ireland. Yet despite its high prevalence (one in eight men), it is also highly survivable, with figures from Cancer Research UK showing that 84 per cent of men diagnosed with the disease live for 10 years or more following treatment.

Huge advances have been made in the past decade in the screening, diagnosis and treatment of prostate cancer. This is good news for men with this diagnosis.

Cancer Treatment

If you have recently undergone treatment for prostate cancer then you will have discussed the treatment options at length with your urologist, oncologist and possibly your surgeon. It will have been a very anxious and difficult time awaiting test results and reading statistics about survival rates. For most men however, the prognosis following one of the life-saving treatments such as radiotherapy, brachytherapy, hormone therapy and surgery is very good. You will have made your decision about which treatment option is best for you based on the advice of your doctors.

The focus around this worrying time is of course on how the treatments will cure the cancer. Radiotherapy (internal or external) uses radiation to kill the cancer cells. Radical prostatectomy (surgery to remove the prostate) is curative if the cancer is isolated to this area. Your doctors will have discussed the side effects of the various treatments but the reality is that most men in this position don’t think too much about the side effects – the focus is on survival. Or if you did absorb some of the information about the risk of incontinence or erectile dysfunction, it is difficult to actually fully discuss the implications and extent of these problems. Sometimes there can also be a “it won’t happen to me” attitude.

Side effects of cancer treatment and their treatment

The side effects of the various treatments are very significant and debilitating and can have a profound affect on quality of life. The good news is that huge amounts can be done to help alleviate these side effects.

Urinary Incontinence

This is the most common side effect following radical prostatectomy and also following radiotherapy. In fact all men will be incontinent for at least a few weeks following surgery to remove the prostate. Knowing a little about the anatomy in the area helps us to understand this.

The prostate gland is a mix of muscle and gland tissue that wraps around the urethra – the tube that carries urine from the bladder to the penis. When the prostate is removed (prostatectomy), so is the muscle within the gland. Therefore because one of the main muscles that helps to regulate the flow of urine has been removed, there will be difficulties with bladder control – leading to incontinence. In addition, immediately after the surgery you will have a catheter inserted.

Luckily, there are other muscles (at the base of the bladder) which also help to regulate the flow of urine. Training bladder and pelvic floor muscles helps the vast majority of men to gain full control. However there is a small percentage of men who will suffer ongoing incontinence because of various other complications related to the surgery. It should be empahasised however that for most men, the prognosis is very good.

The importance of pre-treatment exercises

If possible, it is very important to start bladder control rehabilitation or “pre-habilitation” prior to surgery or radiotherapy. This ensures that the muscle control systems are optimised before the rigours of surgery. It also speeds up recovery of continence dramatically.

Generally it takes about twelve weeks to fully train these muscles. Therefore if you start the programme six weeks before the surgery, there is a good chance that you will be fully continent six weeks after the surgery. Similarly, f you start the programme four weeks before the surgery, you should be dry by eight weeks post-surgery and so on.

After surgery

Immediately after the surgery, you will have a catheter (tube in penis and bag strapped to your leg). This stays in place for about two weeks. During this time, you cannot do pelvic floor exercises. Your focus at this stage should be on resting and recovering from the surgery and gently resuming activities. Don’t overdo things!

However once the catheter has been removed, you can start your rehabilitation. At Evidence-Based Therapy Centre, we have developed a step-by-step programme to optimise your recovery.

What if I had my surgery a long time ago and still have problems with incontinence?

There are several factors which may prevent or delay return of full bladder control. This may be something simple such as not being shown precisely how to carry out the pelvic floor exercises. These muscles can be very difficult for some people to isolate and often men think that they are contracting their pelvic floor muscles when in fact they are drawing in their abdominal muscles or using compensatory strategies such as holding their breath or bracing their tummy.

However there may be something more complex preventing progress – such as nerve damage or anatomical variations that meant the surgery was complicated. Poor bladder control prior to the surgery or other factors like being overweight can also inhibit progress. The specialist chartered physiotherapists at Evidence-Based Therapy Centre can assess you to determine if specialist rehabilitation might benefit you or whether a referral for a specialist surgical opinion is necessary.

Faecal incontinence

This is a less common complaint than urinary incontinence. However sometimes radiation therapy can affect bowel function. Treatment with specific pelvic floor exercises, advice and education can often help resolve this.

Sexual dysfunction

All men will suffer some degree of erectile dysfunction after prostatectomy and most men will have these difficulties after radiation therapy or hormone therapy. Some men recover function spontaneously but most don’t. The problem is that prostate surgery or radiation therapy can damage the nerves that supply the muscles which activate to trap the blood in the penis during an erection. The damaged nerves often heal slowly over about a year. However like any muscle, if these muscles haven’t been used in a long time then they weaken very significantly and may not be strong enough to carry out their function. Therefore although the nerves may have recovered the muscles are too weak to produce or maintain an erection. Other factors can also play a role – loss of elasticity in the penis (because it has not been erect for some time), obesity, pre-treatment problems, fatigue and of course psychological stress following your diagnosis and subsequent treatment. With everything that has been going on, your mind has probably not been focused on this part of your life for some time.

What can be done?

Treatment for erectile dysfunction following prostate cancer is multi-disciplinary. It is important that your doctors are involved. Depending on your situation, it may be important to involve your urologist, a sexual health physician or a general practitioner with a specialist interest in this area. This is because certain medications may need to be prescribed to optimise recovery. Clinical nurse specialists, clinical psychologists and specialist men’s health physiotherapists may also be involved.

From a physical point of view, exercises to optimise the muscle function in the area and also a general exercise programme to improve cardiovascular function are essential components. There are additional physical strategies (such as vacuum pumps to help maintain elasticity) that can be recommended to aid recovery.

This is a difficult topic for most men to discuss. The temptation can be to bottle it all up out of embarrassment or awkwardness. At Evidence-Based Therapy Centre our experienced clinicians can help you to discuss these issues in a caring, empathic, discrete and confidential environment. We won’t push you to disclose these problems but will simply ask if this is an area that you would like to discuss or explore treatment for.

Hormonal side effects

Hormone therapy used to treat prostate cancer (androgen deprivation therapy) can result in many side effects, and these often cause men psychological distress. The symptoms can be similar to those that we associate with the menopause: hot flushes, osteopenia, weight gain, mood swings, reduced muscle mass, hair thinning, gynecomastia [swelling of the breast tissue], fatigue and low libido. This is a complex area that can often require input from a number of different healthcare professionals in different specialities.

At Evidence-Based Therapy Centre, our specialist Men’s Health physiotherapists can assess you and refer you on as required. In addition, our Optimise programme can help with many of these side effects including helping you to manage your weight, improve muscle mass and strength and help energy levels.

Fatigue

Fatigue is the most common side effect of any cancer treatment. Cancer-related fatigue is not relieved well by sleep or rest. It usually decreases significantly after the treatment ends but can persist for months. Recent research showed that one third of patients who had undergone treatment for prostate cancer reported fatigue. Factors that contributed to this included depression, on-going urinary incontinence, pain and insomnia. A number of research studies have demonstrated that a regular exercise programme can help alleviate these symptoms of fatigue. In particular, yoga-based exercise programmes have demonstrated significant improvements in quality of life. Even more importantly, there is increasingly strong research evidence that exercise reduces the progression of prostate cancer by 57% and reduces the recurrence and mortality by 30%.

At Evidence-Based Therapy Centre, we have designed an exercise class specifically for men following treatment for prostate cancer. This programme focusses on the key elements that are important in optimising recovery and incorporates elements of pelvic floor exercise, core stability training, yoga, strength training and cardiovascular exercise.

How does the Optimise programme work?

Step 1 Assessment

If you have undergone treatment for prostate cancer or have a scheduled prostectomy, then the first step is to book an specialist Men’s Health assessment with one of our Men’s Health physiotherapists. This is a one hour appointment where a detailed history will be taken and an examination carried out to determine how we can help.

Step 2 Individual physiotherapy

Usually individual physiotherapy is required to teach effective pelvic floor exericses, (or other relavant individual exercises) and provide individualised advice and education about how to manage any other side effects you may be suffering from.

Step 3 The Optimise exercise programme

Once you are effectively able to carry out pelvic floor exercises and basic core stability exercises, you will usually be ready to start the Optimise exercise programme. This is a 12 week group exercise programme which is tailored to the needs of men recovering from prostate cancer. Different men will have different fitness levels so the class takes account of this and you can build up at your own pace. However all men completing the programme should gain significant improvements in pelvic floor muscle function and core stability, cardiovascular fitness and overall strength and energy levels. In addition, you will have all the skills and knowledge to continue an appropriate exercise regime to help optimise your quality of life after prostate cancer.

The Optimise programme has been developed by specialist chartered physiotherapists Eoin Ó Conaire and Catherine Browne. If you would like to book an assessment, you can call the clinic on 091 727777 or get in touch via the contact page.